Drop the Pop NWT 2012 Funding Application Form

To apply for funding for one ore more projects, please complete and submit this form. Once you have submitted the form, you will receive an automated email confirmation. If you do not receive this, please email healthpromotion@gov.nt.ca.

Deadline is January 6, 2012.

* Denotes Required Fields

Which funding are you applying for?*

Drop the Pop Video Award Funding School-Community Outreach Project Under 100 Club All

Contact Information

Community*
School Name*
School Authority*
Principal’s name*
Contact Person*
Contact's Email Address*

Your Project Objective*

Here are some examples of project objective(s):

Increasing awareness about the importance of healthy eating by conducting classroom, school-wide activities (and in community-wide activities).
Increasing the intake of healthy foods in your school or classroom.
Promoting traditional foods.
Promoting active living through the Under 100 Club (for schools under 100 students).
Providing educational activities to promote healthy eating and the harmful effects of sugary sweetened beverages.
Building the capacity of your students to make healthy foods and snacks.

Enter Your Project Objectives:

Project Description*

Your project description must include an educational component. If you are selecting more than one funding, please include project description for each funding (i.e. Drop the Pop, School-Community Outreach Project, Under 100 Club).

	Project Description
Drop the Pop:
Video Award Funding:
Community-based Drop the Pop Funding:
Under 100 Club:

List Partners*

Parents Students Elders Stores Health Professionals Community Organization

Recreation Coordinator Nutritionist Other If Other, please describe:

Funding

Funding available is based on student population:

Population Size	Drop the Pop	Video Award Funding	Community-based Drop the Pop Funding	Under 100 Club
1 – 50 Students	$750.00	$500.00	$750.00	$1,500.00
51 – 100 Students	$1,000.00	$500.00	$1,000.00	$2,500.00
101 - 140 Students	$1,250.00	$750.00	$1,250.00	Not eligible
141-200 Students:	$1,500.00	$750.00	$1,500.00
201 – 325 Students	$1,750.00	$1,000.00	$1,750.00
> 325 Students:	$2,000.00	$1,000.00	$2,000.00

Enter amount of Funding:	$750	$1000	$1250	$1500	$1750	$2000
	$2500	$3000	$3500	$4000	$4500
	Other	If Other, please enter amount

Budget

		Estimated Budget ($)	Actual Budget (to complete and submit by March 15, 2012)
Drop the Pop	Food Resources*
Drop the Pop	Non-Food Resources*
Video Award Funding
Community-based Funding
Under 100 Club

To be eligible, organizations must agree to the following:

	I agree to provide a year-end financial report showing the actual amount of money spent after we have completed all of our activities (it is recommended that receipts be kept in case for auditing purposes).
	I agree to provide a narrative (activity) report describing all project activities that were completed with the funding.
	I agree that any unspent funding will to be returned to the Department of Health and Social Services.
	I agree to participate and submit surveys and evaluation forms to help Drop the Pop plan for future programs and to assess effectiveness.
	I agree to be contacted for further information that could be used in reports/website/media.
	I agree to provide consent forms for anyone included in a video.